Observations on the nutrient intakes of eating-dependent nursing home residents: underutilization of micronutrient supplements.

OBJECTIVE: To estimate the intakes of essential nutrients by eating-dependent nursing home residents (EDR). METHODS: This study was done in a 190 bed VA nursing home. Thirty-four EDR were selected for the study. Clinical data base which included age, sex, primary diagnosis, body mass index, albumin, hematocrit, activities of daily living status, decubitus ulcer medications and use of multivitamin/trace mineral supplement were recorded from the medical records. Caloric and essential nutrient intakes were determined over a 3-day period by a registered dietitian. RESULTS: Seventy percent (24/34) residents in the study group were underweight (body mass index < 23 kg/m2), 26% were hypoalbuminemic (serum level < 3.5 g/dl), 50% were anemic (hematocrit < 37%); and 38% had pressure ulcers. In 88% EDR, the dietary intakes of three or more essential nutrients were below 50% of the RDA. Most frequent and severely deficient were zinc, copper, and vitamin B6. Despite the inadequate essential micronutrient intakes in the majority of EDR, only 35% received a multivitamin supplement and only 3% received a trace mineral supplement. A survey of 30 other VA nursing homes indicated generally similar findings to those in the Milwaukee facility with regard to the high frequency for eating-dependence, and the low frequency for administration of multivitamin and trace mineral supplements. CONCLUSIONS: Despite eating supervision and assistance, the majority of EDR have inadequate intakes of numerous essential macro- and micronutrients. The deficient micronutrient intakes could be normalized by administration of a multivitamin/trace mineral supplement daily. Nevertheless, only a minority of EDR in VA nursing homes currently receive such a supplement.

The preparation of cross-sectional transmission electron microscopy specimens of Nb/Al multilayer thin films on sapphire substrates.

We have developed a technique for preparation of cross-sectional transmission electron microscopy samples of reacted and unreacted Nb/Al multilayer thin films on sapphire substrates. The choice of substrate was found to be extremely important. Sapphire sputters more slowly than Nb and Nb-compounds and therefore makes it possible to obtain the electron transparent regions in the thin films rather than in the substrate. However, the brittle nature of the sapphire restricts the types of thinning techniques that can be used, requiring extensive ion thinning as a final stage.

Serum fatty acid profile of elderly tube-fed men in a nursing home.

Severely dependent tube-fed elderly men with dementia in this VA nursing home are nourished exclusively with Isocal, which provides only four fatty acids in amounts over 1% of the total (palmitic, oleic, linoleic, and alpha-linolenic). It has not been proven that the frail elderly can efficiently convert linoleic to arachidonic acid, and alpha-linolenic to eicosapentanoic and docosahexaenoic acids. Therefore, we compared the serum profile of fatty acids in six of the tube-fed elderly men with the profile of six healthy young men eating mixed foods ad lib. Expressed as percent of total fatty acids, arachidonic, eicosapentanoic and docosahexaenoic acids did not differ significantly between the two groups. The data show that linoleic and alpha-linolenic acids satisfy the requirements for omega 6 and omega 3 fatty acids, respectively, in severely impaired elderly men.

Subnormal concentrations of serum selenium and plasma carnitine in chronically tube-fed patients.

Forty-seven tube-fed nursing home patients were investigated with regard to serum or plasma selenium (Se), carnitine, and red blood cell (RBC) glutathione peroxidase (GSH-Px). Thirty-six patients were tube fed with Isocal, and 11 were tube fed with Compleat B, an L-carnitine-containing formula. Eighteen elderly nursing home patients and 10 young adults served as controls. Serum Se and plasma carnitine were lowest (p less than 0.05) in the Isocal patients. In all 36 Isocal subjects, Se was below normal, and in 26% of Isocal patients RBC GSH-Px was also below normal. Free and total carnitine were below normal in most Isocal subjects. All 11 Compleat B patients had subnormal serum Se, but most had normal carnitine concentrations. These data suggest that enteral formulae in nursing homes should contain greater than 100 micrograms Se and on the order of a mmol carnitine/1600 kcal.

Hyponatremia in tube-fed elderly men.

Previous reports have described 5-20% prevalence of hyponatremia in extended care facilities, due largely to drugs or inappropriate antidiuretic hormone secretion. In our 400 bed VA extended care facility, 15 men with organic brain syndrome (Alzheimer's, multi-infarct dementia, anoxic encephalopathy or alcoholism) currently receive Isocal via gastrostomy as the sole source of nutrition. We noted intermittent hyponatremia in about half of these patients, and conducted a chart review to investigate the cause. Mean age was 68 yr (range 46-92); tube feeding duration was 3 mo.-3 yr; 266 Na concentrations were obtained from the charts. Simultaneous with these Na analyses, one of three diets prevailed: (A) mixed foods (3-6 g Na/day) orally before gastrostomy; (B) Isocal supplemented with NaCl to give 2 g Na/day; (C) unsupplemented Isocal providing 1 g Na/day. (B) and (C) had been randomly varied by rotating physicians. Serum Na was directly related to Na intake. On (A), Na was within normal range (135-145 mEq/l) in all men. One patient was hyponatremic during diet (B). During (C), eight patients were hyponatremic. Na was less than 135 mEq/l in 40% of all samples during diet (C) and less than 130 mEq/l in 14%. Changing from diet (A) or (B) to diet (C) caused nearly equivalent declines in Na and Cl; K and HCO-3 were unaffected. No hyponatremic patient took drugs known to cause hyponatremia, or had congestive heart failure, hypoalbuminemia, lipemia or fasting hyperglycemia. At the end of the study, four hyponatremic men were changed from (C) to (B); serum Na became normal in all four patients, without edema or hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of the effects of Hepatic-Aid and a Casein modular diet on encephalopathy, plasma amino acids, and nitrogen balance in cirrhotic patients.

Hepatic-Aid is purported to ameliorate encephalopathy and promote positive nitrogen balance in protein-intolerant, cirrhotic patients by correcting their imbalanced amino acid profile. This study evaluated Hepatic-Acid by comparing a 50-g Casein diet with an identical diet with 20-g Casein/30-g Hepatic-Aid per day in a cross-over study. Four patients with biopsy-proven stable cirrhosis, encephalopathy, and under-nutrition were studied. Each study period included three days of equilibration and eight days of metabolic balance, with the following measured at baseline and on balance days 5 and 8: routine biochemistry, fasting ammonia, psychometric tests, EEG, and plasma amino acid profiles. There was no significant change in clinical status, routine biochemistry, fasting ammonia, psychometrics or EEG between the two study periods. Mean (+/-SD) nitrogen balance on the Casein diet at 1.5 +/- 1.5 g/day was not significantly different from that on the Hepatic-Aid diet at 1.5 +/- 1.2 g/day. Plasma amino acid profiles showed a significant fall (p less than 0.05) in fasting and intraprandial tyrosine (tyr) and phenylalanine (phe) on Hepatic-Aid, but only intraprandial leucine (leu), isoleucine (ile), and valine (val) were significantly increased (p less than 0.05) on Hepatic-Aid. The ratio leu + ile + val to tyr + phe was significantly increased (p less than 0.05) on Hepatic-Aid. It is concluded that Hepatic-Aid, as given in this study, maintains N balance similar to Casein, alters the amino acid profile towards normal, but does not ameliorate encephalopathy.

Hypotyrosinemia, hypocystinemia, and failure to retain nitrogen during total parenteral nutrition of cirrhotic patients.

Six patients with gastrointestinal malabsorption and 12 with alcoholic cirrhosis received total parenteral nutrition for 4 wk. Freamine II, the source of the amino acids, is nearly devoid of cystine and tyrosine. We monitored daily nitrogen balance and other nutritional parameters and 22 plasma amino acids. Malabsorbers had a strongly positive nitrogen balance and improvements in nutritional parameters. Plasma amino acids were maintained within or above their normal fasting ranges. Eight of 12 cirrhotics resembled malabsorbing patients in terms of positive nitrogen balance, improved nutritional parameters, and plasma amino acids. In 4 cirrhotics, nitrogen balance remained negative and nutritional repletion failed to occur. Plasma cystine and tyrosine fell to below 30% of their normal fasting means. In 2 of these patients, oral supplements of cystine and tyrosine were given during the fifth week of parenteral nutrition. Plasma cystine and tyrosine were normalized, nitrogen balance became positive, and other repletion indicators demonstrated recovery. We conclude that in 4 cirrhotics, repletion was blocked by deficiencies of cystine and tyrosine, resulting from hepatic inability to synthesize cystine from methionine and tyrosine from phenylalanine.

Hyperalimentation of the cancer patient with protein-calorie undernutrition.

Because protein-calorie undernutrition is common in patients with neoplastic disease, nutritional support is often recommended. It is uncertain, however, that methods of supplemental alimentation successful in noncancerous subjects are suitable in cancer patients. We measured elemental balances, serum proteins, anthropometrics (triceps skinfold and mid-arm muscle area), and creatinine/height ratio in 15 undernourished patients with advanced cancer and in 10 noncancer undernourished controls during central venous or enteral hyperalimentation and found the following. (a) During central venous hyperalimentation, cancer patients showed significantly less improvement than the noncancerous controls in body weight (median increment, 5 kg in cancer patients and 8.5 kg in noncancerous), albumin (0.1 g/dl in cancer patients and 0.5 g/dl in noncancerous patients), creatinine/height ratio (4% of standard in cancer and 10% of standard in noncancer), and mid-arm muscle area (4% of standard in cancer and 11% of standard in noncancer). During enteral hyperalimentation, gains in body weight and albumin by cancer patients were significantly inferior to those in noncancerous subjects. Triceps skinfold increments, in contrast, were similar during both central venous and enteral hyperalimentation for cancer and noncancerous patients. (b) While nitrogen retention was similar in cancer and noncancer patients, the cancer group retained significantly less magnesium and phosphorus (delta Mg in cancer patients, 3.2 mEq/day central, -2.7 mEq/day enteral; delta Mg in noncancer patients, 11.9 mEq/day central, 10.1 mEq/day enteral; delta P in cancer patients, 0.13 g/day central, 0.07 g/day enteral; delta P in noncancer patients, 0.27 g/day central, 0.33 g/day enteral). The poorer balances of cancer patients were caused by increased urinary, not fecal, loss. These findings indicate a partial block in repletion of lean body mass or abnormal composition of newly deposited lean body mass when undernourished patients with advanced cancer receive hyperalimentation.

Enteral versus parenteral nutritional support in cancer patients.

There are many theoretical and practical advantages to enteral rather than parenteral administration of nutrients. However, it is unlikely that enteral supplementation of nutritional intake as presently practiced will be successful as a primary therapy for most patients with the cancer cachexia syndrome. The most likely role of enteral nutritional support (ENS) is in conjunction with other therapies. This modality deserves evaluation in surgery with curative intent. Changes in diet are effective in reducing the gastrointestinal symptoms of abdominopelvic irradiation, but the effect of ENS on the hematologic toxicity of radiation therapy and on response rates and survival is unclear. Elemental diets can reduce the gastrointestinal toxicity of conventional doses of 5-FU, but they worsen the mortality and hematologic toxicity of higher doses. Factors such as protein, fat, and carbohydrate sources, degree of hydrolysis of protein, lactose content, and timing of dietary manipulations are important in evaluating the response to ENS.

Hypocitraturia in patients with gastrointestinal malabsorption.

We measured serum and urinary citrate, oxalate, calcium, and magnesium in 22 normal subjects and in 16 patients with malabsorption. The patients had subnormal levels of serum citrate and magnesium during fasting, subnormal 24-hour levels of urinary citrate, magnesium, and calcium, and excessive levels of urinary oxalate. Daily citrate excretion averaged only 15 per cent of normal. The hypocitraturia in the patients resulted from a subnormal filtered load of citrate and abnormally high net tubular reabsorption of the anion. An oral citrate supplement raised both the serum concentration and the filtered load of citrate to normal fasting values, but net tubular reabsorption remained abnormally high and urinary excretion abnormally low. Intramuscular magnesium sulfate, which corrected the hypomagnesemia and hypomagnesuria, had no effect on serum citrate or its filtered load. Nevertheless the injection restored net tubular reabsorption of citrate to normal and partially improved the hypocitraturia. Full correction of the hypocitraturia was achieved by combined treatment with oral citrate and intramuscular magnesium sulfate. Hypocitraturia may contribute to the formation of oxalate stones in these patients, and therefore our treatment may help to prevent this complication.

Parenteral nutrition of adults with a 900 milliosmolar solution via peripheral veins.

UNLABELLED: The objective of this study was to compare the nutritional value of three parenteral fluids: a conventional solution (400 milliosmoles/liter, containing Na, K, and Cl in 5% glucose); the concentrated hyperalimentation solution of Dudrick (1,800 milliosmoles/liter, containing Na, K, Cl, Mg, Ca, P, and amino acids in 20% glucose); and an experimental solution (900 millisomoles/liter, containing Na, K, Cl, Mg, Ca, P, and amino acids in 6.5% glucose). These three solutions are termed P400, C1,800, and P900, respectively. Preliminary studies showed that when 5 mg of cortisol/liter were added to P900, this fluid could be infused through peripheral veins for as long a time (average 114 hr) as P400 before local reaction necessitated changing the site. When P400 was infused in undernourished subjects without oral intake, balances of N, P, Mg, and Ca/70 kg of body weight per day were strongly negative (-4 g, -0.4 g, -6 mEq, and -0.2 g, respectively), whereas balances of K were about zero and those of Na and Cl were positive. Weight loss occurred. In the same patients, P900 containing 5 mg of cortisol/liter converted balances of N, P, Mg, and K to positive, and stimulated weight gain. Comparison of P900 (containing cortisol) and C1,800 in three emaciated subjects showed that the latter fluid caused a 2 to 4 times greater degree of positive balance in N, P, K, and Mg than the former. Comparison of P900 (containing cortisol) + 670-1700 cal by mouth with C1,800 in four undernourished subjects showed no statistically significant difference between these two programs. CONCLUSIONS: by adding 5 mg of cortisol/liter to P900, the fluid can be infused through peripheral veins. P900 is intermediate in nutritional value between P400 and C1,800. P900 without oral supplement prevents negative balance of all elements except Ca. P900 + daily oral intake of 670-1700 cal is nutritionally equivalent to C1,800.

Effect of antibiotics on growth of the immature rat.

The purpose of this study was to quantify the growth promoting effect of a mixture of antibiotics for rats eating diets deficient in protein or an essential amino acid. Male albino weanling rats (70 to 80 g weight, 4 weeks old) were fed (a) a control diet containing all other required nutrients and varying amounts of casein (0 to 27%), or (b) a purified amino acid diet containing all other required nutrients and varying amounts of valine (0 to 70 mumoles/g diet), threonine (0 to 69 mumoles/g diet) or tryptophan (0 to 8.6 mumoles/g diet), with and without an oral antibiotic supplement consisting of neomycin sulfate (10 mg/100 g body weight/day), bacitracin (500 units/100 g body weight/day), and polymyxin B sulfate (1 mg/100 g body weight/day). At suboptimal intake of casein, valine, tryptophan or threonine, rats eating antibiotic-enriched diet showed up to 3 times greater daily body weight gain (deltaBW) than rats eating a similar diet without antibiotics. The growth-promoting effect of antibiotics can be expressed as percent sparing of specified nutrient (casein or individual amino acid), defined as below: (see journal) where nutrient intakeO ab or nutrient intakeab represents that intake of casein or of a particular amino acid which is required to produce a specific deltaBW in antibiotic-free or antibiotic-supplemented group, respectively. The percent sparing was inversely proportional to the dietary content of casein or limiting amino acid. For diets containing 10% to 25%, 25% to 50%, 50% to 75%, and 75% to 100% of the daily requirement of the limiting nitrogenous nutrient, sparing on the average was greater than 80%, 60%, 20%, and less than 10%, respectively. Data on daily food intake of ad libitum fed rats, and data from an experiment with tube-fed rats, showed that the growth-enhancing effect of antibiotics was independent of changes in food intake.

Effect of intrathecal injection of melanotropic-lipolytic peptides on the concentration of 3',5' cyclic adenosine monophosphate in cerebrospinal fluid.

Rabbits were anesthetized with urethane, and the concentration of 3',5' cyclic adenosine monophosphate (cAMP) in cerebrospinal fluid (CSF) was measured before and after injection into the cisterna magna of the following biologically active peptides and amines; adrenocorticotropin (ACTH), beta-melanocyte-stimulating hormone (beta-MSH), choroid plexus peptide IIF, arginine vasopressin, oxytocin, glucagon, epinephrine, serotonin, histamine, and acetylcholine. Only epinephrine and the lipolytic-melanotropic peptides ACTH, beta-MSH, and IIF influenced cAMP. Five to 500 mug ACTH caused a 3 to 10X increase in cAMP within 30 min; the concentration of nucleotide returned to baseline within 60-90 min after 5 or 50 mug, and remained elevated for at least 120 min after 500 mug. Effects of the same magnitude and tempo as those caused by 5 to 500 mug ACTH were produced by .1 to 10 mug beta-MSH and 5 to 500 mug IIF. Epinephrine at doses of 5 to 500 mug caused rises in cAMP of similar degree as the same dose of ACTH or peptide IIF, but the peak value was not reached until 60 to 90 min after injection.

Hyperdibasicaminoaciduria, hyperammonemia, and growth retardation: Treatment with arginine, lysine, and citrulline.

A 9-year-old girl with hereditary dibasicaminoaciduria has been studied for three years. Initially, clinical features were: growth failure; anorexia and aversion to protein, spontaneous daily protein intake averaging only 10 gm; fasting and postprandial venous hyperammonemia; subnormal plasma concentrations of lysine, arginine, ornithine, and citrulline, with generalized hypermonobasicaminoacidemia; abnormally high renal clearances of lysine, arginine, and ornithine; and intestinal malabsorption of lysine and arginine. Intestinal absorption of citrulline, a precursor of arginine and ornithine, was normal. The patient was observed during four sequential 6-month periods as follows: no treatment (Period I); dietary supplement of arginine and lysine (Period II); dietary supplement of citrulline and lysine (Period III); no treatment (Period IV). During Periods II and III growth rate increased 3- to 4-fold, spontaneous protein intake increased 2- to 3-fold, and abnormalities in blood NH3 and the plasma aminogram were partially corrected. In most respects the citrulline plus lysine supplement was more beneficial than that of arginine plus lysine.

Plasma amino acid patterns during supplemental intravenous nutrition of low-birth-weight infants.

In 42 low-birth-weight infants (smaller than 1,200 gm), we have compared the effects of intravenous nutrition supplement versus conventional feedings on growth, morbidity, mortality, and plasma amino acid patterns. Despite similar total caloric intake in INS and control groups, weight gain was greater in the INS infants. The overall mortality rate did not differ in the two groups. Nonsurviving infants receiving INS lived longer (mean equal to 30 days) than nonsurviving CON infants (mean equal to 5 days). Complications were equally frequent in both groups except that hyperglycemia occurred more often in infants receiving INS. The plasma aminogram of the LBW infant is described and compared to those of the full-term infant and adult. Hypoaminoacidemia was present at birth in the LBW infants, concentrations of glutamine, alamine, glycine, histidine, and ornithine being significantly (P smaller than 0.05) below FT values. During INS, elevations of threonine, serine, and methionine above FT values occurred. Glutamine remained subnormal despite INS. Recommendations for an INS solution more suitable for use in LBW infants are presented.

Elemental balances during intravenous hyperalimentation of underweight adult subjects.

Intravenous hyperalimentation was done in 11 underweight adults whose body weight (body wt) was less than 85 percent of ideal. For the first 6 days, "complete formula" was infused furnishing per kilogram ideal body wt per day: 15 g glucose, 0.40 g N, 0.018 g P, 2.4 meq K, 3.0 meq Na, 2.3 meq C1, 0.5 meq Mg, 0.45 meq Ca, and 50 ml H20. Patients gained weight at an average rate of 9.0 g/kg ideal body wt/day and showed average balances/kilogram ideal body wt/day as follows: plus 0.14 g N; plus 0.012 g P; plus 0.43 meq K; plus 0.49 meq Na; plus 0.37 meq Cl; and plus 0.085 meq Ca. Application of standard equations to the elemental balances indicated weight gain consisted of 35-50 percent protoplasm, 35-50 percent extracellular fluid, 5-25 percent adipose tissus, and less than 1 percent bone. Withdrawas of N, P, Na, or K impaired or abolished retention of other elements. Removal of N halted retention P, K, Na and C1; withdrawal of K stopped retention of N and P; and removal of Na or P interrupted retention of all other elements. Weight gain continued at a rate of 1.4-3.1 g/kg ideal body wt/day despite zero or negative elemental balances of N, K, P, and sometimes Na and C1. Calculations showed that weight gain during infusion of fluids lacking N, P, K, or Na consisted largely of adipose tissue, with little or no contribution by protoplasm or extracellular fluid. Data show that repletion of protoplasm and extracellular fluid of wasted adults by intravenous hyperalimentation is retarded or abolished if N, P, Na, or K is lacking. Repletion of bone mineral does not occur in absence of Na or P but proceeds in absence of N, P, K, or Na. Thus, quality of weight gained by underfed adult patients during hyperalimentation depends on elemental composition of the infusate.